Culprit Artery Localization in STEMI: Insights from a Cardiology Presentation
Localization of culprit artery in
Localization of culprit artery in
STEMI
STEMI
Topic presentation
Topic presentation
Speaker
Dr.Suneesh.K
Senior Resident, Dept. of Cardiology
Calicut Medical College
•
Introduction
•
Coronary circulation and blood supply of the heart
•
AWMI
•
IWMI
•
RVMI
•
PWMI
•
Conduction disturbances
•
Atrial Infarction
•
Exercises
Overview
Overview
15-09-2024
Introduction
•
Careful analysis of the surface ECG is highly useful in
localizing the culprit vessel and immediate prognostication
•
Helps in deciding the need for an aggressive reperfusion
strategy
•
ECG correlation of infarct related artery predict moratlity in
acute myocardial infarction
Prevalence of STEMI
Newby et al, GUSTO Study J Am Coll Cardiol1996;27:625-32
Coronary circulation
Left Main or left coronary artery
•
LAD
Diagonal braches (D1, D2)
Septal branches
•
Circumflex
Marginal branches (M1, M2)
Right coronary artery
•
Conus, sinoatrial branch
•
RV branch
•
Acute marginal branch
•
AV nodal branch
•
Posterior descending artery (PDA)
Blood supply of heart
•
LAD
–
Supplies the anterior, lateral, anterior two-thirds of septum, and
frequently the inferoapical segments of LV, including the
proximal part of bundle branches
•
RCA
–
Perfuses SA node (65%), AV node, postero-medial papillary
muscle, inferior part of LV, RV, and variably also the posterior
and lateral segments
•
Circumflex branch
–
Posterior wall and variably inferior and lateral segments
–
Posterior wall involvement
usually underestimated and
under treated
Blood supply of heart (contd..)
•
SA node – RCA in 65%
•
AV node – RCA in 90%
•
Bundle of His – Mainly RCA
•
RBB – LAD
•
LBB – L Ant branch – LAD
•
LBB - L Post branch – LAD & PDA
Blood supply of heart (contd..)
Dominance
•
Supplies circulation to the inferior wall and inferior
portion of the posterior IVS
•
Dominant artery passes crux and IVS, giving rise to
posterolateral branches and PDA
•
Dominant artery also gives rise to the AV nodal branch
•
Nondominant artery is usually smaller in size and
terminates early in its respective AV groove
Dominance
•
RCA – 70%
•
LCX – 10%
•
Co- dominant – 20%
Right dominant
Left dominant
The concept of injury vector:
Direct and reciprocal changes
•
Injury vector is oriented towards the injured area and generates
STE in the leads facing the vector’s head
•
ST-segment depression in the leads facing the vector’s tail
(opposed leads)
•
Leads perpendicular to dominant vector will record an iso-
electrical ST segment
Proximal occlusion of long LAD
Distal occlusion of long LAD
Ischemia at a distance Vs reciprocal
changes
•
Patients with ST elevation in one territory often have ST depression in
other territories
•
The additional ST deviation may represent acute ischemia due to coronary
artery disease in non infarct related arteries (ischemia at a distance) or may
represent pure "mirror image" reciprocal changes
•
Most of the common patterns of remote ST depression probably represent
reciprocal changes and not “ischemia at a distance”
AWMI
AWMI
Anteroseptal zone: occlusion of the
LAD and its branches
•
Proximal to 1
st
septal and 1
st
diagonal branch (40%)
•
Distal to S and D (40%)
•
Proximal to D1 but distal to S1 (5-10%)
•
Proximal to S1 but distal to D1 (5-10%)
•
Selective D1–D2occlusion
•
Selective S1–S2 occlusion
Proximal LAD occlusion
(Dominance of Basal area)
Injury vector is directed anteriorly and upward, and somewhat to the right or left
Proximal LAD occlusion
(Dominance of Basal area)
•
STE aVR and STE in V1
>
2.5 mm
•
ST depression in inferior leads and in V5
•
Abnormal Q in aVL
•
ST depression in the inferior wall (III +aVF ≥2.5
mm) is quite suggestive of a proximal occlusion of
LAD above D1
Proximal LAD occlusion
(Dominance of Basal area)
Distal LAD occlusion
(Dominance of inferoapical area)
Distal LAD occlusion
(Dominance of inferoapical area)
•
Inferior third of the LV & low-lateral involvement (apical
infarction)
•
Injury vector is directed forward and left, and downward
•
STE in inferior leads (II > III) in addition to V3-V6
•
Slight ST-segment depression in aVR
•
Wide Q V4-V6 some times
Distal LAD occlusion
(Dominance of inferoapical area)
STE is seen in the precordial and inferior leads in the presence of
a STEMI due to the very proximal occlusion of the RCA
In this case the STE usually is V1>V3−4, while in a STEMI due
to the distal occlusion of the LAD the opposite occurs
(i.e., the STE is V1<V3−4)
1
st
Diagonal not involved
(Dominance of septal area)-Proximal to S1
1
st
Diagonal not involved
(Dominance of septal area)-Proximal to S1
Injury vector is directed anteriorly, to the right and sometimes downward
•
Antero-septal infarction
•
STE in aVR and
>
2.5 mm STE in V1
•
ST elevation from V1to V3−4and II, III, and aVF
•
ST depression in V6, I and aVL
•
STE in V3R
•
RBBB/ QRBBB
1
st
Diagonal not involved
(Dominance of septal area)-Proximal to S1
1
st
Diagonal not involved
(Dominance of septal area)-Proximal to S1
First septal branch not included
(Dominance of Lateral area) – Prox to D1
Injury vector is directed anteriorly, upward, and somewhat to the left
•
ST elevation lead AVL & lead I
•
Q left lateral leads
•
ST depression in Lead III > Lead II
•
ST depression in (III + aVF) ≥ 2.5 mm
First septal branch not included
(Dominance of Lateral area) – Prox to D1
First septal branch not included
(Dominance of Lateral area) – Prox to D1
First septal branch not included
(Dominance of Lateral area) – Prox to D1
ECG criteria to identify site of
occlusion in the LAD
New QRBBB in V1 is a specific but insensitive marker of proX LAD occlusion
New QRBBB in V1 is a specific but insensitive marker of proX LAD occlusion
•
Area affected -Mid-low anterior wall and part of the mid- and
often low-lateral wall
•
Injury vector is directed upward, to the left and forward
•
STE in I, aVL and
precordial leads V2−V6
(Variable)
•
ST depression in II, III, and VF (III >II)
Selective occlusion of the D1branch
Selective occlusion of the D1branch
Selective occlusion of the S1branch
•
Septal wall with occasionally certain extension toward
the anterior wall
•
Injury vector directed anteriorly, upward, and to the
right
•
STE in V1,V2, and aVR
•
ST depression in II, III, aVF (II>III), and V6
•
No ST elevation in aVL
Selective occlusion of the S1branch
Algorithm for ECG Identification of the Infarct-Related Artery in AW-STEMI
Engelen DJ, Gorgels AP, Cheriex EC et al
J Am Coll Cardiol 1999; 34:389-95
IWMI
IWMI
Injury vector in RCA and LCX
Right coronary
Circumflex coronary
V5 and V6 are of little value in differentiating between RCA or Cx
occlusion. STE in these leads implies a larger area at risk
Occlusion of the RCA
•
ST elevation in III > II
•
ST depression in I and aVL - aVL > I
•
ST depression in the right precordial leads is smaller than
STE in inferior leads
•
When occlusion is proximal to RV branches ST E in V1 >
V3 V4
•
When RCA is dominant, STE is seen in V5 and V6 (Local
injury vector)
•
Involvement of posterior wall
•
RCA very dominant or super dominant - STE elevation ≥ 2
mm in V5-V6 and ST depression in I and aVL
Eskola et al. 2004
Occlusion of the RCA (Contd..)
Occlusion of the LCX
•
ST- elevation in II ≥ III
•
ST elevation in I and aVL or isoelectric
(rarely)
•
STE in II, III, and aVF is usually smaller than the ST
depression in right precordial leads
•
When LCX is quite dominant - ST depression in aVL,
but
very rarely in I and STE 4-5 mm in v5-v6
•
ST depression in aVR - Involvement of either the LCX or the RCA with a large
posterolateral (PL) branch
•
The specificity and sensitivity for lead aVR to predict LCX involvement - 94%
and 70%, respectively
Zhang YZ et al . The value of ECG lead aVR
in the differential diagnosis of acute IWMI. Intern Med, 2007; 46: 795–799
•
Decrease in R-wave amplitude and an increase in S-wave amplitude with an
S/R ratio of >1:3 in aVL predict RCA occlusion, whereas an S/R ratio of 1:3
or less predict LCx occlusion
Assali AR et al. Electrocardiographic criteria for
predicting the culprit artery in IWMI. Am J Cardiol, 1999; 84: 87–89
Proximal occlusion of a very dominant LCX
First step:
Assess the ST-segment in lead I
STD
RCA
Isoelectric-
Proceed to 2
nd
step:
STE in II, III, aVF
STE
LCX
II > III
LCX
III > II
Proceed to 3
rd
step:
Ʃ STD V1-V3
Ʃ STE II, III, aVF
> 1
LCX
< 1
RCA
Fiol M A et al;
Value of electrocardiographic algorithm based on “ups and
downs” of ST in assessment of a culprit artery in IWMI
Am J Cardiol, 2004; 94: 709–714
OM VS D1 occlusion
RVMI
RVMI
RV infarction
RV infarction
•
STE >1mm V3R and V4R
•
STE V1 > V2
•
High degree AV block
•
Sometimes STE in V1 with STD in V2 (Discordant
relationship)
STD in V3
STE in III
Less than
0.5
0.5 to 1.2
More
than 1.2
LCx artery
Sens 84%
Spec 95%
Distal RCA
Sens 84%
Spec 93%
Proximal RCA
Sens 91%
Spec 91%
Kosuge M
, Kimura K, Ishikawa T et al.
New electrocardiographic criteria for predicting the culprit artery in
inferior wall acute myocardial infarction. Am J Cardiol, 1998; 82: 1318–1322
V4R in acute infero posterior MI
STE III>II
STD in I, aVL or both (>1mm)
RCA
Sensitivity 90%
Specificity 71%
PPV 94%
NPV 70%
STE I, aVL, V5 and V6
STD in V1,V2,V3
LCX
Sensitivity 83%
Specificity 96%
PPV 91%
NPV 93%
In addition, STE in V1, V4R, or both
Proximal RCA with RVMI
Sensitivity 79%
Specificity 100%
PPV 100%
NPV 88%
Zimetbaum et Al; NEJM 2003
STEMI due to proximal RCA occlusion
STEMI due to RCA occlusion distal to the RV
branches
Very dominant RCA occlusion distal to the
RV branches
Proximal occlusion of a very dominant LCX
Isolated RVMI
•
Minor changes in inferior leads, but STE prominent in leads
V1 and V2 and right precordial leads (V3R and V4R)
•
Due to either a small or collaterally filled RCA or an occlusion
of an RV branch only
PWMI
PWMI
Posterior wall involvement
•
ST depression in the precordial leads
•
May extend from V1 to V6 and indicate larger MI
•
Maximal ST depression in V4 – V6 is seen more in
three vessel disease and lower LVEF
•
Can occur both in RCA and Cx artery involvement
Posterior wall involvement
•
In case of LCX occlusion posteriorwall involvement is almost obligatory
•
Absence of precordial ST depression in inferior wall infarction is therefore strongly
suggestive of RCA involvement
•
Isolated ST depression V1-V3– LCx occlusion with a true PWMI or nonocclusive
myocardial ischemia
•
Max ST depression in V2 and V3 is predictive of LCx
•
V7 –V9 shows ST elevation even though less amplitude
True PWMI
•
ST depression in V1, R/S >1, and upright T wave
V1
V9
•
Marked down sloping ST depression in I, II, and V4 – V6 and
STE in aVR
•
aVR STE occurred more in LMCA than in LAD
•
V1 STE was less in LMCA than LAD
•
High mortality rate in those with higher STE in Avr
Yamaji H et al J Am Coll Cardiol 2001;38:1348-1354
Left main stem occlusion or
triple vessel disease
Left main stem occlusion or
triple vessel disease
•
Acute LMCA occlusion rare but causes serious
hemodynamic deterioration
•
More commonly, subtotal occlusion occurs with collaterals
filling from RCA
presents as Unstable angina
•
ECG of subtotal occlusion similar to triple vessel disease
Conduction disturbances
Conduction disturbances
AV conduction disturbances
•
AV nodal delay and block occurs with proximal RCA
involvement, frequently with RVMI
•
Higher in-hospital morbidity & mortality
Sub AV conduction disturbances
•
RBBB with or without hemiblock during acute AWMI
indicates proximal LAD
•
BBB or CHB indicates poor prognosis
•
LAHB in acute IWMI indicates additional LAD disease
Atrial infarction
•
Signs of atrial MI are seen in PTa segment
•
PTa segment elevation occurs in I, II, III, V5 or V6 or a
depression in precordial leads
•
Occurs in 10 % of inferoposterior MI
•
Isolated occurrence is rare
•
Proximal RCA or Cx
Acute MI : ECG subsets and correlated
infarct related artery and mortality
Gusto I cohort population Topol EJ; ed 1998
Limitations
•
Assessment of the site of occlusion of coronary vessel by ECG is most reliable in
case of 1
st
MI
•
Impaired
–
Multivessel disease
–
Collateral circulation
–
When ventricular activation is prolonged as in
•
LVH
•
Preexistent LBBB
•
Preexcitation
•
Paced rhythm
Dr. Suneesh K., a Senior Resident in the Dept. of Cardiology at Calicut Medical College, delves into the crucial role of ECG analysis in identifying the culprit artery during ST-elevation myocardial infarction (STEMI). This presentation covers coronary circulation, blood supply of the heart, prevalence of STEMI, and the significance of immediate prognosis based on ECG findings. Explore how surface ECG correlations can guide reperfusion strategies and predict mortality in acute myocardial infarction cases.
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Presentation Transcript
Localization of culprit artery in Localization of culprit artery in STEMI STEMI Topic presentation Speaker Dr.Suneesh.K Senior Resident, Dept. of Cardiology Calicut Medical College
Overview Overview Introduction Coronary circulation and blood supply of the heart AWMI IWMI RVMI PWMI Conduction disturbances Atrial Infarction Exercises 15-09-2024
Introduction Introduction Careful analysis of the surface ECG is highly useful in localizing the culprit vessel and immediate prognostication Helps in deciding the need for an aggressive reperfusion strategy ECG correlation of infarct related artery predict moratlity in acute myocardial infarction
Prevalence of STEMI Prevalence of STEMI Inferior 58% Anterior 39% Other 3% Newby et al, GUSTO Study J Am Coll Cardiol1996;27:625-32
Coronary circulation Coronary circulation Left Main or left coronary artery LAD Diagonal braches (D1, D2) Septal branches Circumflex Marginal branches (M1, M2) Right coronary artery Conus, sinoatrial branch RV branch Acute marginal branch AV nodal branch Posterior descending artery (PDA)
Blood supply of heart Blood supply of heart LAD Supplies the anterior, lateral, anterior two-thirds of septum, and frequently the inferoapical segments of LV, including the proximal part of bundle branches RCA Perfuses SA node (65%), AV node, postero-medial papillary muscle, inferior part of LV, RV, and variably also the posterior and lateral segments
Blood supply of heart (contd..) Blood supply of heart (contd..) Circumflex branch Posterior wall and variably inferior and lateral segments Posterior wall involvement usually underestimated and under treated
Blood supply of heart (contd..) Blood supply of heart (contd..) SA node RCA in 65% AV node RCA in 90% Bundle of His Mainly RCA RBB LAD LBB L Ant branch LAD LBB - L Post branch LAD & PDA
Dominance Dominance Supplies circulation to the inferior wall and inferior portion of the posterior IVS Dominant artery passes crux and IVS, giving rise to posterolateral branches and PDA Dominant artery also gives rise to the AV nodal branch Nondominant artery is usually smaller in size and terminates early in its respective AV groove
Dominance Dominance RCA 70% LCX 10% Co- dominant 20%
Right dominant Right dominant
Left dominant Left dominant
The concept of injury vector: The concept of injury vector: Direct and reciprocal changes Direct and reciprocal changes Injury vector is oriented towards the injured area and generates STE in the leads facing the vector s head ST-segment depression in the leads facing the vector s tail (opposed leads) Leads perpendicular to dominant vector will record an iso- electrical ST segment
Proximal occlusion of long LAD Proximal occlusion of long LAD Distal occlusion of long LAD Distal occlusion of long LAD
Ischemia at a distance Vs reciprocal Ischemia at a distance Vs reciprocal changes changes Patients with ST elevation in one territory often have ST depression in other territories The additional ST deviation may represent acute ischemia due to coronary artery disease in non infarct related arteries (ischemia at a distance) or may represent pure "mirror image" reciprocal changes Most of the common patterns of remote ST depression probably represent reciprocal changes and not ischemia at a distance
AWMI AWMI
Anteroseptal zone: occlusion of the Anteroseptal zone: occlusion of the LAD and its branches LAD and its branches Proximal to 1st septal and 1st diagonal branch (40%) Distal to S and D (40%) Proximal to D1 but distal to S1 (5-10%) Proximal to S1 but distal to D1 (5-10%) Selective D1 D2occlusion Selective S1 S2 occlusion
Proximal LAD occlusion (Dominance of Basal area) Injury vector is directed anteriorly and upward, and somewhat to the right or left
Proximal LAD occlusion (Dominance of Basal area)
Proximal LAD occlusion (Dominance of Basal area) STE aVR and STE in V1 > 2.5 mm ST depression in inferior leads and in V5 Abnormal Q in aVL ST depression in the inferior wall (III +aVF 2.5 mm) is quite suggestive of a proximal occlusion of LAD above D1
Distal LAD occlusion Distal LAD occlusion (Dominance of inferoapical area) (Dominance of inferoapical area)
Distal LAD occlusion Distal LAD occlusion (Dominance of inferoapical area) (Dominance of inferoapical area)
Distal LAD occlusion Distal LAD occlusion (Dominance of inferoapical area) (Dominance of inferoapical area) Inferior third of the LV & low-lateral involvement (apical infarction) STE is seen in the precordial and inferior leads in the presence of Injury vector is directed forward and left, and downward a STEMI due to the very proximal occlusion of the RCA STE in inferior leads (II > III) in addition to V3-V6 In this case the STE usually is V1>V3 4, while in a STEMI due Slight ST-segment depression in aVR to the distal occlusion of the LAD the opposite occurs Wide Q V4-V6 some times (i.e., the STE is V1<V3 4)
1 1st st Diagonal not involved Diagonal not involved (Dominance of septal area) (Dominance of septal area)- -Proximal to S1 Proximal to S1
1 1st st Diagonal not involved Diagonal not involved (Dominance of septal area) (Dominance of septal area)- -Proximal to S1 Proximal to S1 Injury vector is directed anteriorly, to the right and sometimes downward
1 1st st Diagonal not involved Diagonal not involved (Dominance of septal area) (Dominance of septal area)- -Proximal to S1 Proximal to S1 Antero-septal infarction STE in aVR and > 2.5 mm STE in V1 ST elevation from V1to V3 4and II, III, and aVF ST depression in V6, I and aVL STE in V3R RBBB/ QRBBB
1 1st st Diagonal not involved Diagonal not involved (Dominance of septal area) (Dominance of septal area)- -Proximal to S1 Proximal to S1
First septal branch not included First septal branch not included (Dominance of Lateral area) (Dominance of Lateral area) Prox to D1 Prox to D1 Injury vector is directed anteriorly, upward, and somewhat to the left
First septal branch not included First septal branch not included (Dominance of Lateral area) (Dominance of Lateral area) Prox to D1 Prox to D1 ST elevation lead AVL & lead I Q left lateral leads ST depression in Lead III > Lead II ST depression in (III + aVF) 2.5 mm
First septal branch not included First septal branch not included (Dominance of Lateral area) (Dominance of Lateral area) Prox to D1 Prox to D1
First septal branch not included First septal branch not included (Dominance of Lateral area) (Dominance of Lateral area) Prox to D1 Prox to D1
ECG criteria to identify site of ECG criteria to identify site of occlusion in the LAD occlusion in the LAD
New QRBBB in V1 is a specific but insensitive marker of proX LAD occlusion
Selective occlusion of the D1branch Selective occlusion of the D1branch Area affected -Mid-low anterior wall and part of the mid- and often low-lateral wall Injury vector is directed upward, to the left and forward STE in I, aVL and precordial leads V2 V6 (Variable) ST depression in II, III, and VF (III >II)
Selective occlusion of the D1branch Selective occlusion of the D1branch
Selective occlusion of the S1branch Selective occlusion of the S1branch Septal wall with occasionally certain extension toward the anterior wall Injury vector directed anteriorly, upward, and to the right STE in V1,V2, and aVR ST depression in II, III, aVF (II>III), and V6 No ST elevation in aVL
Selective occlusion of the S1branch Selective occlusion of the S1branch
Algorithm for ECG Identification of the Infarct-Related Artery in AW-STEMI Engelen DJ, Gorgels AP, Cheriex EC et al J Am Coll Cardiol 1999; 34:389-95
IWMI IWMI
Injury vector in RCA and LCX Injury vector in RCA and LCX
Right coronary Right coronary Circumflex coronary Circumflex coronary Inferoseptal ischemia Inferoposterolateral ischemia Vector directed to III Directed to II STE III > II STE II > III ST depression in aVL>I STE I or aVL or both RV can be involved True PWMI can occur V5 and V6 are of little value in differentiating between RCA or Cx occlusion. STE in these leads implies a larger area at risk
Occlusion of the RCA Occlusion of the RCA ST elevation in III > II ST depression in I and aVL - aVL > I ST depression in the right precordial leads is smaller than STE in inferior leads When occlusion is proximal to RV branches ST E in V1 > V3 V4
Occlusion of the RCA (Contd..) Occlusion of the RCA (Contd..) When RCA is dominant, STE is seen in V5 and V6 (Local injury vector) Involvement of posterior wall RCA very dominant or super dominant - STE elevation 2 mm in V5-V6 and ST depression in I and aVL Eskola et al. 2004
